Failure to Administer Ordered Nutritional Supplements and Dietary Items
Penalty
Summary
Certified Medication Technician (CMT) D failed to provide nutritional supplements as ordered to four residents, all of whom had physician orders and care plans specifying the need for supplements such as Ensure or Med Pass 2.0. Observations revealed that these supplements were not present on meal trays, not available on medication carts, and not administered during medication passes, despite CMT D initialing the Medication Administration Record (MAR) to indicate they had been given. Interviews with the CMT and other staff confirmed that the supplements were not administered as ordered, and the CMT admitted to documenting administration when it had not occurred, citing a lack of stock, which was contradicted by the Central Supply Clerk who confirmed adequate supply was available. Multiple residents with significant weight loss, malnutrition, and other medical conditions such as anemia, renal insufficiency, and pressure ulcers were affected by the failure to administer supplements. For example, one resident with a history of severe protein-calorie malnutrition and a stage 2 pressure ulcer did not receive Ensure as ordered, and another resident with cognitive impairment and a history of weight loss did not receive Med Pass 2.0. Observations also showed that dietary orders for whole milk were not followed, with residents being served 2% milk instead, and staff failing to verify or correct discrepancies between menu slips and what was served. Interviews with facility staff, including the Central Supply Clerk, Dietary Manager, and Administrator, confirmed that the responsibility for administering supplements and ensuring correct dietary items rested with both nursing and dietary staff. However, the process failed at multiple points, including communication, documentation, and direct care. The Medical Director stated an expectation that facility policies and physician orders be followed, but the observed and documented failures resulted in residents not receiving prescribed nutritional support.